Rural community care teams, shared care coordination, and improved community outcomes

This case study presents the development of the Ely Community Care Team (CCT), located in a geographically remote, rural region with limited resources. The CCT is creating a local approach to improve health outcomes and reduce unnecessary health care usage, adapting care management and interorganizational teaming for this rural community. Care coordination, one key strategy in the Accountable Care Act, holds promise for improving health, including behavioral health, outcomes while reducing costs. The presentation will describe development of the interdisciplinary team, including its successes and challenges, and the results of the evaluation of the pilot of the care coordination model. The evaluation, guided by community-based participatory research tenets, collected information through interviews and electronic surveys with team members, observation in the community, and electronic data collection from patients who participated in care management. Team members identified community needs, made recommendations for the development of care coordination, and described relationships between organizations participating in the CCT. Using social network analysis, characteristics of organizational relationships, patterns of referrals and sharing funding and data are described. Patient reported wellness outcomes (the SF-36 and the Patient Assessment of Chronic Illness Care) and changes in service usage, for instance, decreased emergency room use, are presented to demonstrate the impact of CCT on patients. The case study provides guidance for further implementation of the CCT; for the development of a care coordination model for potential implementation in other rural communities; and for further research regarding the impact of care coordination on health outcomes in rural communities.